Karapandzic Flap for Reconstruction of Lip Defects

J Oral Maxillofac Surg 65:2512-2517, 2007

Karapandzic Flap for Reconstruction of Lip Defects Madanagopalan Ethunandan, BM, MDS, FDSRCS, FFDRCS, MRCS,* David W. Macpherson, FRCS, FDSRCS,† and Vijay Santhanam, FDSRCS‡ Purpose: Systematic evaluation of the Karapandzic flap in the reconstruction of lip defects after

ablative surgery. Patients and Methods: Patients who had a Karapandzic flap to reconstruct lip defects were analyzed

with reference to demographic details, histology and location of the tumor, and dimensions of resection. The functional aspects of the reconstruction were assessed in terms of the size of the oral stoma, preservation of oral competence, and facial expression, in addition to speech, diet and ease of cutlery, and denture usage. The esthetic outcome was assessed with a 4-point scale and in addition the symmetry of the commissure at rest and function, preservation of the philtrum, and lip projection also were assessed. The complications were noted. Results: Seven patients underwent Karapandzic flap reconstruction (4 males, 3 females) with an age range of 43 to 98 years. Three tumors were located in the upper lip, 4 in the lower lip, and there were 5 squamous and 2 basal cell carcinomas. The lip defects ranged from 40% to 75% of the lip circumference. The oral stoma was of a reduced circumference in all cases but did not lead to any functional compromise in terms of oral competence, facial expression, speech, diet, denture and cutlery usage, and sensation. There were no wound complications in our series. The esthetic outcome was considered excellent/good in 85% of cases. The commissure was symmetrical in all except 1 patient, the philtrum was preserved in all cases of lower lip reconstruction, and the projection of the lip was reduced in edentulous patients. Conclusions: The Karapandzic flap is a reliable technique that offers consistently good functional and esthetic outcomes after reconstruction of lip defects. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:2512-2517, 2007 Carcinoma of the lip is a common problem encountered by clinicians and surgery is often the recommended modality of treatment. Full-thickness defects of up to one third of the lip can be closed by direct apposition of the wound edges with excellent results. Larger defects require the use of local and distant flaps. The functional and esthetic results after reconstruction of large lip defects can be disappointing and the numerous techniques described in the literature

Received from the Maxillofacial Unit, St Richard’s Hospital, Chichester, United Kingdom. *Specialist Registrar. †Consultant. ‡Locum Registrar. Address correspondence and reprint requests to Dr Ethunandan: Maxillofacial Unit, St Richard’s Hospital, Chichester, PO19 4SE, UK; e-mail: [email protected] © 2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6512-0019$32.00/0 doi:10.1016/j.joms.2006.10.018

stand testimony to the shortcomings of the individual procedures.1,2 An ideal reconstructive technique would involve a 1-stage procedure, replacing lost tissue with similar tissue from an adjacent donor site. In addition, the technique should be reliable and importantly, restore esthetics and function. It would come as no surprise that there is no single ideal technique that can be used in all situations. In 1974, Karapandzic3 described a neurovascular myocutaneous flap that addresses most of the above criteria and is said to offer very satisfying results in selected cases. In this study, we evaluated our experience of using the Karapandzic flap to reconstruct lip defects after ablative surgery.

Patients and Methods We systematically evaluated patients who were to have a Karapandzic flap to reconstruct lip defects after ablative surgery, at St Richard’s Hospital, Chichester. The factors analyzed were the demographic

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details of the patients, histology and location of the tumors, and the dimensions of resection. The size of the oral stoma was noted and the functional aspects of the reconstruction were assessed in terms of preservation of oral competence and facial expressions. Speech, postoperative diet, cutlery, and ease of denture usage also were evaluated. Speech was assessed in terms of intelligibility by the clinician and the patient. Diet and cutlery usage were compared with pretreatment status and any modifications necessary in the postoperative period was noted. Similarly, the use of dentures preoperatively were noted and their use and any modifications made in the post-treatment period documented. The esthetic outcome was assessed by a 4-point scale with particular attention being paid to the appearance and location of the scar, symmetry of the commissures at rest and function, preservation of the philtrum, and lip projection. The assessments were subjective and were made by the clinician examining the patient and reviewing photographs. LIP ANATOMY AND OPERATIVE TECHNIQUE

The oral sphincter is composed of the circumferential fibers of the orbicularis oris muscle and the radial orientation of the elevators and depressors from its outer margins. In addition, the sensory and motor nerves supplying the lips and the labial vessels also enter this area in a radial fashion. This anatomy was exploited by Karapandzic and forms the basis of the flap. The lesion is excised with adequate margins to leave a rectangular defect. Starting at the base of the rectangle the skin incision is outlined parallel to the lip margins and along the mentolabial and nasolabial folds (Fig 1). The incision is deepened through skin

FIGURE 2. Lesion excised and the flap raised preserving the incoming nerves and vessels. Ethunandan, Macpherson, and Santhanam. Karapandzic Flap. J Oral Maxillofac Surg 2007.

and subcutaneous tissues, after which blunt dissection is used in a radial fashion, along the directions of the incoming nerves and vessels that should be preserved, to detach the lateral margin of the orbicularis oris from its attachments to obtain the required mobility (Fig 2). Although it has been suggested that the individual radial muscles are identified, divided, and subsequently sutured in their original position, we have not found this necessary. Mucosal incisions in the vestibule are required only adjacent to the margins of the defect to enable closure. The wound is then closed in layers, taking care to obtain a good muscular apposition (Fig 3).

Results

FIGURE 1. Excision margins and the Karapandzic flap marked out. Ethunandan, Macpherson, and Santhanam. Karapandzic Flap. J Oral Maxillofac Surg 2007.

Seven patients (4 males, 3 females) underwent Karapandzic flap reconstruction for lip defects. The age range was 43 to 98 years (median, 71 years), and all but 1 patient was over 60 years of age. There were 5 squamous cell carcinomas (SCCs) and 2 basal cell carcinomas (BCCs). Three tumors including both the BCC cases were located in the upper lip and 4 tumors were located in the lower lip. Four tumors involved the commissures and 3 were located centrally. The extent of resection varied from 40% to 75% and all except 1 resection involved more than 50% of the lips (Table 1). The oral stoma was of a reduced circumference in all the patients evaluated. All patients were able to eat a normal diet postoperatively without any modifications required to the meals or the cutlery used. Four patients had a denture preoperatively and 1 underwent a dental clearance intraoperatively. All 5 pa-

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FIGURE 3. Wound closed in layers. Ethunandan, Macpherson, and Santhanam. Karapandzic Flap. J Oral Maxillofac Surg 2007.

tients were able to use their dentures postoperatively without any modifications (Fig 4). All except 1 patient, who had an ulcerated BCC in the upper lip, were considered to have normal speech and oral competence preoperatively. After the procedure, all 7 patients were considered to have normal speech and were able to carry out a full range of facial expressions and maintain oral competence. The lip sensation was considered normal on pin prick and light touch testing. Three patients were considered to have an excellent result, 3 a good result, and 1 a satisfactory result. There was some rounding of the commissure at rest in the initial postoperative period but this improved in the first few months and all but 1 patient was considered to have a symmetrical commissure at rest and during function subsequently (Fig 4). The philtrum was preserved in all patients who had a lower lip reconstruction (Figs 5, 6) and was not reconstituted in the case of upper lip resections, all of which involved the philtrum preoperatively (Fig 4). The projection of the lips was decreased in the case of edentulous patients (Figs 3, 6) and was re-established with the insertion of the dentures (Fig 4). All the lesions were excised completely and there were no problems with wound infection, breakdown, or hematoma formation.

Discussion Lips have a prominent place in our psyche and have many and varied connotations. In addition to their

undoubted esthetic appeal, they have an important role to play in maintaining oral competence and speech, which are in turn dependent on a relatively normal morphology and an intact motor and sensory nerve supply. Lip cancer accounts for almost 30% of oral cavity tumors and along with the cutaneous malignancies in this region, is a common condition presenting to the clinician and surgery is often the recommended modality of treatment. The lip is a composite structure containing skin, muscle, and mucous membrane, and any reconstruction should aim to replace the lost tissue. Although full-thickness excisions of up to one third of the lip can be closed by direct apposition of the wound edges, larger defects necessitate the use of local and distant flaps. These flaps can be divided broadly into those that redistribute the remaining lip tissue and those that bring additional tissue to the circumference of the lips.1,2,4,5 The choice is often dependent on the extent of the excision, with defects of up to 70% to 80% of the lips being reconstructed by redistribution of lip tissue and larger defects requiring the use of additional tissue. Although the cross lip flaps of Abbe and Estlander and the Gilles fan flap and its modifications are the most well known of the flaps that redistribute the lip tissue,1,2,5 Karapandzic described the neurovascular myocutaneous flap that is based on a similar principle.3 The important difference being the preservation of an intact motor and sensory nerve supply and avoiding additional transection of the orbicularis oris muscle fibers, thereby minimizing denervation and atrophy of the sphincter and enhancing movement and sensation. In our series, 7 patients underwent Karapandzic flap reconstruction for lip defects after ablative surgery for lip cancer. The size of the defects ranged from 40% to 75% of the lips and the median age of the patients was 71 years. Lip cancer is a disease of the elderly and the laxity of the lips in this group of patients facilitates the use of the Karapandzic flap. Although the size of the stoma was decreased in all patients in our series as expected, none had any functional problems as a result of the relative microstomia. The neo-stoma in all our patients was sufficient to allow a normal diet and use of regular cutlery and was able to accommodate the dentures without any modifications. The critical size of the stoma before the development of functional problems is uncertain, but is likely to be influenced by the laxity of the perioral tissues and the preservation of motor and sensory innervation. The necessity for secondary procedures to correct microstomia has been reported to be around 24% and was often for patients who had total or near total lip resections.3 In our series, resections of up to 75% of the lip was reconstructed with-

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Table 1. SUMMARY OF PATIENT DETAILS

Number

Age/Gender

Histology

Dimensions of Resection

Site of Resection

Commisure Involvement

Esthetic Outcome

1

43/Male

BCC

44 ⫻ 26 mm

Yes

Satisfactory

2

82/Female

BCC

42 ⫻ 22 mm

No

Excellent

3

71/Female

SCC

28 ⫻ 18 mm

No

Excellent

4

70/Male

SCC

45 ⫻ 25 mm

No

Excellent

5

89/Male

SCC

45 ⫻ 35 mm

Yes

Good

6

98/Female

SCC

48 ⫻ 25 mm

Yes

Good

7

62/Male

SCC

50 ⫻ 40 mm

Yes

Good

Abbreviations: BCC, basal cell carcinoma; SCC, squamous cell carcinoma. Ethunandan, Macpherson, and Santhanam. Karapandzic Flap. J Oral Maxillofac Surg 2007.

out the need for secondary surgery to widen the oral sphincter and is similar to the findings of Jabaley et al.4 Speech, facial expressions, and oral competence were unaffected in all our patients after the reconstruction, no doubt aided by the presence of a neosphincter with an intact motor and sensory nerve supply. These finding are similar to those reported in

other reviews,3-7 although we are not aware of any articles evaluating objectively the functional outcome in this group of patients. The appearance of the reconstruction was considered to be excellent or good in 6 patients and satisfactory in 1 patient. The outcome was considered excellent in patients who had central defects and good in lateral defects involving the commissure. In

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FIGURE 6. Postoperative appearance at 6 months, showing a normal philtrum and reduced lip projection without the denture in place. Ethunandan, Macpherson, and Santhanam. Karapandzic Flap. J Oral Maxillofac Surg 2007. FIGURE 4. Postoperative appearance at 1 month, with full denture in place and showing normal motor function. Ethunandan, Macpherson, and Santhanam. Karapandzic Flap. J Oral Maxillofac Surg 2007.

all the patients in whom the defect involved the commissure, the incision in the vermillion was made obliquely to increase the surface area. There have been some concerns regarding the appearance of a “rounded” commissure after reconstruction with a Karapandzic flap.7 In our series, although there was some rounding of the commissure in the early postoperative period, this settled spontaneously and all except 1 patient was considered to have a symmetrical commissure at rest and during function. The patient who was considered to have a satisfactory outcome also was the youngest patient in the series with a large tumor of the upper lip, involving the commissure and necessitating additional resection of part of the alar base, nasal floor, and columella. The outcome

FIGURE 5. Preoperative appearance of a large lower lip tumor. Ethunandan, Macpherson, and Santhanam. Karapandzic Flap. J Oral Maxillofac Surg 2007.

was considered satisfactory due to the asymmetrical commissure, which could be improved by revision surgery. In our series, the flap was used to reconstruct upper and lower lip defects with satisfying results. Though the Karapandzic flap has often been described to reconstruct defects of the lower lip,1,2,5,7 in his initial description Karapandzic3 used the flap to reconstruct upper and lower lip defects. The philtrum is one of the defining characteristics of the upper lip and some authorities have suggested that it should be avoided as a donor site for lower lip defects,1 given the complexity of reconstructing the philtrum. In our series, the philtrum was preserved in all patients who had the lower lip defects reconstructed with a Karapandzic flap (Fig 6). In the case of upper lip defects, however, the reconstruction did not reconstitute the philtrum, although it was possible to place the vertical component of the scar in this region (Fig 4), due to the differential movements offered by the apposing wound edges of the raised flap. In addition the upper lip projects in front of the lower lip in most individuals and is often dependent on its bony and dentoalveolar support. In our series the projection of the reconstructed lip was decreased in the case of edentulous patients, but was compensated easily by adjustments to their dentures. There were no wound complications associated with the procedure in our series and confirms the excellent reliability of the vascular supply to the flap. Although none of our patients underwent a simultaneous neck dissection or had previous radiotherapy that might interfere with the vascular supply, its use has been reported in patients who had previous radiotherapy3 although its use in patients undergoing simultaneous neck dissection remains untested.

ETHUNANDAN, MACPHERSON, AND SANTHANAM

In summary, the Karapandzic flap is a reliable technique that offers consistently good functional and esthetic outcomes. It can be used to reconstruct significant upper and lower lip defects and we feel it should be included in the armamentarium of all surgeons treating lip cancers.

References 1. McGregor IA, McGregor FM: Cancer of the Face and Mouth. Edinburgh, Churchill Livingstone, 1986

2517 2. Baker SR, Swanson NA: Local Flaps in Facial Reconstruction. St Louis, Mosby, 1995 3. Karapandzic M: Reconstruction of lip defects by local arterial flaps. Br J Plast Surg 27:93, 1974 4. Jabaley ME, Orcutt TW, Clement RL: Applications of the Karapandzic principle of lip reconstruction after excision of lip cancer. Am J Surg 132:529, 1976 5. Smith PG, Muntz HR, Thawley SE: Local myocutaneous advancement flaps—Alternatives to cross-lip and distant flaps in the reconstruction of ablative lip defects. Arch Otolaryngol 108:714, 1982 6. Clairmont AA: Versatile Karapandzic lip reconstruction. Arch Otolaryngol 103:631, 1977 7. Calhoun KH: Reconstruction of small and medium sized defects of the lower lip. Am J Otolaryngol 13:16, 1992